Why Insurance?: Part 2 - Access

Health insurance is not the same as health care which is not the same as health. When we talk about “health care reform,” the changes we are addressing relate to how health care is paid for—who does the paying, and how do providers receive those payments. As I discussed in my first post, Obamacare is based on the idea that every individual should have health insurance. This ideal begs the question: What are the benefits of being insured? Over a series of three articles, I will examine the relationships between health insurance and the three key issues of health, access to care, and financial protection.

You wake up one morning with a dull, cloudy feeling in your head—is it the flu or just a bad cold? You go for a run and twist your ankle—is it broken or just a nasty sprain? These questions could be answered by a medical professional, but your ability to ask them and to receive the care you need depends on one crucial aspect of the healthcare system: access.

In the United States, people may lack access to medical care for any of several reasons. They may live in a place where there is no medical facility nearby. The medical facility may exist, but be unwilling to treat them. Or they themselves might be unwilling to seek treatment, afraid of what the financial consequences might be. In any of these instances, the outcome is the same: They do not have access to appropriate medical care.

Having health insurance is an important part of improving access to care. Making sure people can seek medical treatment when they need it is one of the central arguments in support of expanding the availability of affordable health insurance. However, having coverage is not always enough to remove every barrier to care.

Part of the difficulty is that not all insurance plans are the same. Although a patient may be “covered,” the costs to the patient of receiving care, or to a doctor of providing care, can still prevent patients from receiving the treatment they need.

In the late 1970s, the RAND Corporation found that how often people sought medical care depended on how much they had to pay for it under their insurance plan. Those with plans that required them to pay for some percentage of their care, perhaps unsurprisingly, used fewer health services compared to those who received care free of charge. Importantly, the study assessed the degree to which seeking care was “effective” (the patient had a condition known to be improved with the type of care sought), and found that use of both effective and ineffective care-seeking decreased when cost to the patient increased. In other words, having to pay anything, even less than the full cost of care, was sometimes enough to deter a patient from seeking medical help.

This issue of seeking care appropriate to the patient’s need was highlighted in a recent article produced as part of the ongoing Oregon Health Insurance Experiment (OHIE). Some proponents of universal health insurance believe that coverage would allow people to stop going to emergency rooms (which are legally mandated to treat all patients) for conditions that could be treated by a primary care doctor. Contrary to that expectation, the OHIE study found that individuals newly enrolled in Medicaid visited emergency rooms slightly more often than individuals who were eligible for, but not enrolled in, the public insurance program.

As Harold Pollack points out, the reasons for the increase probably relate to cost—going to the ER is less expensive for those on Medicaid than for the uninsured, making them more willing to seek treatment when they think they need it. The fact that ER visits increased for both urgent and non-urgent care might also point to a barrier to care that insurance alone cannot address—the absence of appropriate care options such as a lack of primary care doctors in a patient’s neighborhood.

Even stickier than the issue of where patients seek care is the question of whether doctors will agree to see patients. Not all types of health insurance pay doctors the same amount of money for providing the same treatment Perhaps most prominently, Medicaid, the public health program for the poor, pays providers significantly less than private plans. As a result, many providers feel they must limit the number of Medicaid patients they treat, making it difficult for those patients to find care. Despite having insurance, access is still denied.

Despite these limitations, there is little doubt that individuals with insurance are in an improved position to receive care relative to those without. Patients with conditions like diabetes that require daily medications can fill their prescriptions more reliably and at lower cost when they are insured. For those who are generally healthy, having insurance can be one less reason to hesitate before getting checked out for a bad fever or swollen ankle.

When it comes down to it, the biggest contribution insurance makes toward access is in the form of protection from the financial concerns associated with seeking care, a topic we’ll explore in the third part of this series. If we believe every individual should have access to medical treatment, then affordable health insurance is an important first step—but certainly, not the last.

This article is Part 2 of a three-part series by Anna Stapleton called “Why Insurance?”